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Filing # 124034035 E-Filed 03/30/2021 03:40:26 PM
IN THE CIRCUIT COURT OF THE 17™ JUDICIAL CIRCUIT IN AND
FOR BROWARD COUNTY, FLORIDA
Case No. CACE-21-003836 Div. 09
STEVIE BAZILE, individually,
and WILSON JEAN LOUIS, her
husband,
v.
Plaintiffs,
COMPLETE HIGHWAY IMPROVEMENT, INC.,
A Florida Corporation, CITY OF NORTH LAUDERDALE,
And WESNER ABRAHAM, individually,
Defendants.
/
DEFENDANT, CITY OF NORTH LAUDERDALE’S
FIRST REQUEST FOR PRODUCTION TO PLAINTIFF
Defendant, CITY OF NORTH LAUDERDALE (‘‘City”), by and through its undersigned
attorneys and pursuant to Rule 1,350 of Florida Rules of Civil Procedure, requests Plaintiff,
STEVIE BAZILE (“Plaintiff”), produce within thirty (30) days of the date of this Request at the
office of the undersigned, the following:
1,
Individual and/or joint income tax returns corporate returns and any other supporting
documentation, including W-2 forms, for the five (5) years preceding the alleged
accident/incident to date or any other evidence of income for each of said years. If there
are returns requested which you do not have in your immediate possession or custody,
please fill out and sign the enclosed release and return it in response to this request.
All documentation which would reflect Plaintiffs earnings for the present year to date (this
would include payroll stubs, canceled checks, computer printouts of earnings to date, etc.).
Any and all medical, doctor, hospital, drug, nursing and ambulance medical records,
reports, bills, and invoices (including any members of the healing arts and related fields:
i.e. drugs, prosthetics, supports, etc.) pertaining to the Plaintiff, to the extent they pertain
to any and all injuries or damages you alleged were caused by the incident giving rise to
this lawsuit pertaining to any treatment described in your answers to interrogatories. This
request also seeks documentation for any expenses that you claim you have incurred as a
result of this accident/incident, which includes but is not limited to bills and invoices for
household assistance and out-of-pocket expenses, etc. If there are medical records and
*** FILED: BROWARD COUNTY, FL BRENDA D. FORMAN, CLERK 03/30/2021 03:40:25 PM.****16.
documents requested which you do not have in your possession or custody, please fill out
and execute the attached medical records release and return it in response to this request.
All x-rays, cat scans, MRIs, EKGs, EEGs and/or other scans of the Plaintiff, to the extent
they pertain to any and all injuries or damages you allege were caused by the incident
giving rise to this lawsuit or pertaining to any treatment described in your answers to
interrogatories. If there are x-rays or scans requested which you do not have in your
immediate possession or custody, please fill out and sign the enclosed medical records
release and return it in response to this request.
All medical bills and/or statements, correspondence (including but not limited to letters of
protection), and related documents for services rendered to the Plaintiff, paid or unpaid, as
an alleged result of the incident giving rise to this suit, including any bills for drugs or other
related expenses.
All bills, statements, or receipts relating to an expense claimed as damages in this lawsuit
which have not been produced in response to any of the preceding paragraphs.
All reports and related documents related to any issue in this lawsuit which have been
prepared by experts that you intend to call as witnesses in this cause.
All statements taken from any agents or employees of Defendant regarding the incident
sued upon.
All photographs, diagrams, sketches, or other documents depicting the scene of the alleged
incident.
. All photographs, diagrams, sketches, or other documents depicting your injuries or
damages.
. All statements taken from any witnesses having knowledge regarding the facts and
circumstances surrounding the happening of the incident complained of herein.
. All documents pertaining to the sued-upon incident or your physical condition or damages.
. All releases, "Mary Carter Agreements," and any other type of settlement documents
between the Plaintiff and any other party which may have been responsible for the alleged
damages claimed by the Plaintiff.
- All photographs, recordings, charts, graphs, sketches and any other documents or tangible
items which you intend to use during the trial of this cause and which have not been
produced in response to any of the preceding paragraphs.
. All documents which you identify in response to Interrogatories served this date.
All documents which you contend support your compliance with all conditions precedent
to bringing this action.20.
21.
22.
23.
24,
25.
26.
27.
28.
29.
. Your Medicare card.
. Your Medicaid card.
. Your Social Security Disability card.
Your Supplemental Security Income card.
Your applications for Medicare or Medicaid benefits during the past 10 years.
Your applications for Social Security benefits including but not limited to Social Security
Disability and/or Supplemental Security Income benefits during the past 10 years.
All Social Security award letters you have received during the past 10 years.
All documents regarding any and all Medicare benefits identified in your Answer to the
Medicare Interrogatories served on this date.
All documents regarding any and all Medicaid benefits identified in your Answer to
Medicare Interrogatories served on this date.
All documents regarding your current Medicare, Medicaid, Social Security Disability
and/or Supplemental Security Income recipient status as identified in your Answers to the
Interrogatories served on this date.
All documents and communications regarding any and all requests for hearing for Social
Security Disability and/or Supplemental Security Income benefits identified in Answer the
Interrogatories served on this date.
So that both parties can be in full compliance with all Medicare reporting and
reimbursement requirements, a complete and executed two forms: CMS (A-1) and
Authorization Form (marked as A-2), attached.
As to each type of insurance in force of favor of the Plaintiff, including, but not limited to,
medical insurance, hospitalization insurance, Medicare, Medicaid, disability insurance,
medical payments insurance, personal injury protection, health insurance and accident
insurance:
Copies of each such contract or policy;
The Identification Card of each such contract policy;
The Declaration Sheet of each such contract or policy:
Each and every application for benefits made by the Plaintiff under any of the
policies, whether pertaining to the accident which is the subject of this litigation or
not;
e. All records or payments, checks, check stubs, memos and correspondence relating
to payments made under any of the policies referred to above; and
BeoPpf. All documents reflecting billing codes including but not limited to ICD9 codes
relating to Medicare coverage, treatment, and payments.
30. Any and all photographs intended to be used at trial depicting any all parties and/or
witnesses, the injury and the damages sustained by the person(s) involved in the
accident/incident herein, the scene and/or site of the accident/incident as described in your
Complaint.
31. All reports, evaluations, recommendations and/or analysis submitted by any expert which
relate to or cover the accident/incident which is the subject matter of this lawsuit and/or
any injuries, damages or losses allegedly caused by the accident/incident.
32. Copies of any and all medical reports and/or records from doctors, physicians (including
chiropractors), hospitals, or anyone else of the healing arts who has rendered treatment to
you or examined you subsequent to the accident/incident herein which is the subject matter
of this lawsuit. (This would include both treating physicians as well as independent medical
exams).
33. Copies of any and all writings, recordings, memorandums, notes, depositions, and all other
materials reflecting statements made by the Defendant.
34. Legible copies of all applications filled out by you for Personal Injury Protection Benefits
(No fault Insurance Benefits) by the accident/incident which is the subject matter of this
lawsuit.
35. Legible copies of all applications filled out by you for any type of insurance coverage for
which you are submitting an application to obtain benefits for any of your damages and/or
wages of the accident/incident as alleged in your Complaint.
36. Legible copies of each and every document, chart, paper, graph, employment record,
payroll record, time sheets and/or other writings of any type evidencing each and every day
or partial day, you claim to have missed from work as a result of the accident/incident
which is the subject matter of this lawsuit.
37. Legible copies of any and all checks, PIP payout sheets and/or writings that indicate the
amount of money, if any, that you have received as reimbursement for lost wages, medical
bills (or other bills) from your Personal Injury Protection Policy or any other collateral
sources.
38. Legible copies of any and all letters of subrogation rights or liens being asserted by any
third party/entity as a result of any damages you have sustained as a result of the
accident/incident as described in the Complaint.
39. Legible copies of any and all reports, charts, graphs, or other writings from any vocational
specialist, rehabilitative consultants and/or other experts that have assisted you or evaluated
you with regard to damages claimed in this lawsuit.40. Legible copies of any and all diagnostic test results, including but not limited to x-rays, CT
scans, MRI films, EMG, NCS, and other electrical studies that were performed on the
claimant(s) as a result of the accident which is the subject matter of this lawsuit.
. Production of all diagnostic test results of any and all x-rays, CAT scans, CT scans, MRI
scans, ultrasounds, thermograms, EMG and NCS studies that were performed on you
during the five-year period prior to the accident/incident as described in your Complaint.
tS
42. Legible copies of the front and back of any and all insurance indemnification card and
union employment identification cards which would depict the name, address, policy
number, claim number and/or identification number of any insurance company and/or
employers which will provide you with any benefits to compensate you for any of the
damages that you are alleging as a result of the accident/incident which is the subject matter
of this lawsuit.
43. Any and all statements, documents, correspondence, chart, or other writing of any type
taken from Plaintiffs employers and/or their agents pertaining to employment, wage loss,
loss of future earning capacity or the loss of the ability to earn money in the future which
would support your allegations in the Complaint.
44, Please provide legible copies of any and all accident reports, incident reports or other
reports that were generated as a result of the accident/incident that is the subject matter of
your Complaint.
45. Incident reports and/or traffic accident reports for any and all accidents that you have been
involved in within the ten (10) year period before the accident giving rise to this case, and
for any and all accidents that you have been involved in since the occurrence of the accident
which is the subject matter of this lawsuit.
46. Please provide legible copies of any Notice of Injury forms that you have filled out for any
workman's compensation claim, or workman's compensation notice, that you are required
to fill out as a result of any type of on-the-job injury or incident for the past five (5) years
to date.
47. Copies of any and all life, health, or disability insurance policies covering the claimant in
this lawsuit that were in full force and effect on the date of the accident which is the subject
matter of this lawsuit.
48. Copies of any and all statements taken of any witnesses (written or recorded) as a result of
the accident/incident which is the subject matter of this lawsuit.
49. Copies of the front and back of all driver's licenses in your possession.
50. Copies of any Florida identification cards, front and back.
51. A complete copy of your passport.52
53.
54.
55.
56.
57.
Copies of any Releases you may have executed to any party, person, entity for personal
injuries that you may have sustained or property damage you suffered in the past twenty
(20) years.
Please provide legible copies of all medical reports and records that were made by and
physicians or chiropractor regarding any examination that was conducted upon you at the
request of any insurance company or insurance adjusting company (otherwise known as
IME's, independent evaluations, medical evaluations, or physical examinations) which
occurred as a consequence of the accident/incident as described in your Complaint.
Please provide legible copies of all medical reports and records that were made by and
physician or chiropractor regarding any examination that was conducted upon you at the
request of any insurance company or insurance adjusting company (otherwise known as
IME's, independent evaluations, medical evaluations, or physical examinations) for the five
(5) years prior to the incident.
Copies of any calendars, diaries, notes, or other documentation made by you which
memorializes any appointments, your condition, thoughts, damages, or any other item of
damages you intend to present to the jury at the trial of this case.
Please execute and return the attached authorization for the release of insurance, hospital
records, medical records, and medical billing information pertaining to the Plaintiff for all
the medical providers for whom the Plaintiff has received medical treatment for any reason
prior to the incident described in the Complaint and for any time after the incident described
in the Complaint.
Please execute and return the attached authorization for the release of tax returns and
records. (PLEASE NOTE: The original authorization must be mailed back to undersigned
counsel. A photocopy is not acceptable).CERTIFICATE OF SERVICE
I HEREBY CERTIFY that a copy hereof has been served and filed through the Florida
Court E-Filing Portal thisdD Tsay of March, 2021 to: Brett R. Bloch, Esq., Shendell & Pollock,
P.L., 2700 North Military Trail, Suite 150, Boca Raton, FL, 33431, brett @shendellpollock.com,
lisak@shendellpollock.com, Stephanie@shendellpollock.com, grs@shendellpollock.com, Ian D.
Pinkert, Esq., Jay Halpern & Associates, PA, 150 Alhambra Circle, Suite 100, Coral Gables,
Florida, 33134, ian@hsptrial.com.
MELISSA L. JOHNSG
FLA. BAR NO. 275.
Attorney for City of North Lauderdale
JOHNSON, ANSELMO, MURDOCH,
BURKE, PIPER & HOCHMAN, P.A.
2455 E. Sunrise Blvd., Suite 1000
Fort Lauderdale, FL 3330
Tel: 954-463-0100/Fax: 954-463-2444-
mljohnson@jambg.com
berens@jambg.com
finley@jambg.comAUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION AND RECORDS
(HIPAA COMPLIANT
TO: STEVIE BAZILE
DOB:
SOC SEC.:
YOU ARE HEREBY INSTRUCTED AND REQUESTED to release to Melissa L. Johnson,
Esq., Johnson, Anselmo, Murdoch, Burke, Piper & Hochman, P.A., 2455 E. Sunrise Blvd.,
Suite 1000, Fort Lauderdale, FL 33304; (954) 463-0100., the following:
YOUR ENTIRE FILE INCLUDING BUT NOT LIMITED TO ANY AND ALL medical,
insurance, hospital, psychiatric, or other mental health treatment records, reports, admission and
discharge summaries, consultations, nurses’ notes, diagnostic tests. reports of x-rays, CT Scans,
MRI notes; documents; reports; test results; diagnostic studies; results of examinations conducted;
correspondence; any and all X-rays, CT scans, MRI films, and all other radiographic studies and
associated reports, results, interpretations; all pathology slides, tissue blocks, specimens, etc., all
other pathologic studies and associated reports, results, interpretations; consultation reports,
inpatient, emergency or out-patient records, photographs, any and all bills for services rendered,
HIV testing records/results; psychological/psychiatric records, including, but not limited to,
substance abuse counseling records and HIV counseling records; and copies of all other materials
ete., bills, correspondence or other documentary or tangible items regarding my mental or physical
condition while under your observation or treatment, and to permit the examination of, and the
copying of records pertaining thereto. This facility is released and discharged of any liability and
the undersigned will hold the facility harmless for complying with this "Authorization for Release
of Medical Information." This Authorization is valid through the completion of litigation styled
STEVIE BAZILE, individually, and WILSON JEAN LOUIS, her husband, Case No.: CACE-21-
003836 Div. 09. A PHOTOSTATIC COPY OF THIS AUTHORIZATION SHOULD LIKEWISE
BE HONORED,
(THIS SECTION HAS BEEN INTENTIONALLY LEFT BLANK)
(Page | of 2)AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION AND RECORDS
(HIPAA COMPLIANT.
STEVIE BAZILE
STATE OF FLORIDA )
)ss
COUNTY OF )
Sworn to (or affirmed) and subscribed before me by means of physical presence
or online notarization, who after being first duly sworn, deposes and states that he/she
answered the Interrogatories, and the facts contained therein are true and correct to the best of
his/her knowledge and belief.
SWORN TO AND SUBSCRIBED before me this day of :
2021, by 7 . who is personally known to me, or who has produced
_ as identification.
Notary Public, State of Florida at Large
Printed Name:_
(NOTARY SEAL)
My commission expires:
(Page 2 of 2)CATS, AL Medicare
Beneficiary Services: 1-800-MEDICARE (1-800-633-4227)
(CENTERS for MEDICARE & MEDICAID SERVICES.
TTY/1DD:1-877-486-2048
This form is used to advise Medicare of the person or persons you have chosen to have access to your
personal health information.
Where to Return Your Completed Authorization Forms:
After you complete and sign the authorization form, return it to the address below:
Medicare BCC, Written Authorization Dept.
PO Box 1270
Lawrence, KS 66044
For New York Medicare Beneficiaries ONLY
The New York State Public Health Law protects information that reasonably could identify someone as
having HIV symptoms or infection, and information regarding a person's contacts. Because of New York's
laws protecting the privacy of information related to alcohol and drug abuse, mental health treatment, and
HIV, there are special instructions for how you, as a New York resident, should complete this form.
* For question 2A, check the box for Limited Information, even if you want to authorize Medicare
to release any and all of your personal health information.
¢ Then proceed to question 2B,
Medicare BCC. Written Authorization Dept.
PO Box 1270
Lawrence, KS 66044FORM A-2
Authorization to Release Information
nawe: STevie Caria
(if applicable, exactly as shown on your Medicare card)
SOCIAL SECURITY NUMBER:
MEDICARE NUMBER (HICN):
(if applicable, the number on your Medicare card)
DATE OF BIRTH:
DATE OF INJURY/ILLNESS:
In compliance with the Federal Privacy Act of 1974 and the HIPAA Privacy Rule, the
undersigned authorizes the Centers for Medicare &Medicaid Services (CMS), and their
contractors, to release to
or its/their designee(s), agent(s) and representative(s) (collectively "the Company") any
and all information concerning conditional payments made by Medicare resulting from
the personal injury/illness, which occurred/was diagnosed on or about the date listed
above.
The undersigned also hereby authorizes the Company to disclose my
personal-information (including but not limited to my Social Security number) and
information related to my injury/illness and any settlement for the specified injury/illness
to CMS and its contractors.
The undersigned also hereby authorizes the Company to disclose my Social Security
number to the Social Security Administration to determine social security benefits (for
the purposes of determining Medicare eligibility).
This form expires in three years from the date of execution; however, | understand that |
may revoke this "Authorization to Release Information" at any time.
SIGNED: DATE:Instructions for Completing Section 2B of the Authorization Form:
Please select one of the following options.
* Option 1 To include all information, in the space provided, write: "all information, including
information about alcoho! and drug abuse, mental health treatment, and HIV". Proceed with the rest
of the form.
* Option 2 To exclude the information listed above, write "Exclude information about alcohol and
drug abuse, mental health treatment and HIV" in the space provided. You may also check any of the
remaining boxes and include any additional limitations in the Space provided. For example, you
could write "payment information". Then proceed with the rest of the form. .
If you have any questions or need additional assistance, please feel free to call us at 1-800-MEDICARE
(1-800-633-4227). TTY users should call 1-877-486-2048,
Sincerely,
1-800-MEDICARE
Customer Service Representative
Encl.Information to Help You Fill Out the
“1-800-MEDICARE Authorization to Disclose Personal Health Information” Form
By law, Medicare must have your written permission (an “authorization”) to use or give out
your personal medical information for any purpose that isn't set out in the privacy notice
contained in the Medicare & You handbook. You may take back (revoke”) your written
permission at any time, except if Medicare has already acted based on your permission.
If you want 1-800-MEDICARE to give your personal health information to someone other than
you, you need to let Medicare know in writing.
If you are requesting personal health information for a deceased beneficiary, please include a
copy of the legal documentation which indicates your authority to make a request for
information. (For example: Executor/Executrix papers, next of kin attested by court documents
with a court stamp and a judge's signature, a Letter of Testamentary or Administration with a
court stamp and judge's signature, or personal representative papers with a court stamp and
Judge's signature.) Also, please explain your relationship to the beneficiary.
Please use this step by step instruction sheet when completing your “1-800- MEDICARE
Authorization to Disclose Personal Health Information” Form. Be sure to complete all sections
of the form to ensure timely processing.
1. Print the name of the person with Medicare.
Print the Medicare number exactly as it is shown on the red, white, and blue Medicare
card, including any letters (for example, 1234567894).
Print the birthday in month, day, and year (mm/dd/yyyy) of the person with Medicare,
2, This section tells Medicare what personal health information to give out. Please check a
box in 2a to indicate how much information Medicare can disclose, If you only want
Medicare to give out limited information (for example, Medicare eligibility), also check
the box(es) in 2b that apply to the type of information you want Medicare to give out.
3. This section tells Medicare when to start and/or when to stop giving out your personal
health information. Check the box that applies and fill in dates, if necessary,
4, Medicare will give your personal health information to the person(s) or organization(s) you
fill in here. You may fill in more than one person or organization. If you designate an
organization, you must also identify one or more individuals in that organization to whom
Medicare may disclose your personal health information,x
. The person with Medicare or personal representative must sign their name, fill in the date,
and provide the phone number and address of the person with Medicare.
If you are a personal representative of the person with Medicare, check the box, provide
your address and phone number, and attach a copy of the paperwork that shows you can
act for that person (for example, Power of Attomey).
Send your completed, signed authorization to Medicare at the address shown here on your
authorization form.
If you change your mind and don't want Medicare to give out your personal health
information, write to the address shown under number six on the authorization form and
tell Medicare. Your letter will revoke your authorization and Medicare will no longer
give out your personal health information (except for the personal health information
Medicare has already given out based on your permission).
You should make a copy of your signed authorization for your records before mailing it to
Medicare.Department of Health and Human Services Form Approved
OMB No. 0938-0930
Centers for Medicare & Medicaid Services.
1-800-MEDICARE Authorization to Disclose Personal Health Information
Use this form if you want 1-800-MEDICARE to give your personal health information to someone
other than you.
STé vie. Eazile
1. Print Name Medicare Number Date of Birth
(First and last name of the person with Medicare) (Exactly as shown on the Medicare Card) (mm/dd/yyyy)
2, Medicare will only disclose the personal health information you want disclosed.
2A: Check only one box below to tell Medicare the specific personal health information you
want disclosed:
C] Limited Information (go to question 2b)
LF Any Information (go to question 3)
2B: Complete only if you selected “limited information”. Check all that apply:
[J Information about your Medicare eligibility
| Information about your Medicare claims
[] Information about plan enrollment (e.g. drug or MA Plan)
LC] Information about premium payments
CE Other Specific Information (please write below; for example, payment information)
2C: NY Residents Only, this section must be completed.
Please select one of the following options: (Please check only one box.)
| Include all information. This includes information about alcohol and drug abuse, mental
health treatment, and HIV.
OR
C] Exclude information about alcohol and drug abuse, mental health treatment, and HIV.
Form CMS-10106 (Rev 09/17)Department of Health and Human Services Form Approved
Centers for Medicare & Medicaid Services OMB No. 0938-0930
3. Check only one box below indicating how long Medicare can use this authorization to disclose
your personal health information (subject to applicable law—for example, your State may limit
how long Medicare may give out your personal health information):
LI Disclose my personal health information indefinitely
EC] Disclose my personal health information for a specified period only
beginning: (mm/dd/yyyy) and ending: (mm/dd/yyyy)
4. Fill in the reason for the disclosure (you may write "at my request"):
5. Fill in the name and address of the person or organization to whom you want Medicare to
disclose your personal health information. Please provide the specific name of the person for
any organization you list below. If you would like to authorize any additional individuals or
organizations, please add those to the back of this form.
Name
Address
Name
Address
Form CMS-10106 (Rev 09/17)Department of Health and Human Services Form Approved
Centers for Medicare & Medicaid Services OMB No. 0938-0930
Note: You have the right to take back (“revoke”) your authorization at any time, in writing, except
to the extent that Medicare has already acted based on your permission. To revoke authorization,
send a written request to the address noted below. Y our authorization or refusal to authorize disclosure
of your personal health information will have no effect on your enrollment, eligibility for benefits, or the
amount Medicare pays for the health services you receive.
6.
I authorize 1-800-MEDICARE to disclose my personal health information listed above to
the person(s) or organization(s) I have named on this form. I understand that my
personal health information may be re-disclosed by the person(s) or organization(s) and
may no longer be protected by law.
Signature Telephone Number Date (mm/dd/yyyy)
Print the address of the person with Medicare (Street Address, City, State, and ZIP)
C] Check here if you are signing as a personal representative and complete below.
Please attach the appropriate documentation (for example, Power of Attorney). This only
applies if someone other than the person with Medicare signed above.
Print the Personal Representative's Address (Street Address, City, State, and ZIP)
Telephone Number of Personal Representative:
Personal Representative's Relationship to the Beneficiary:
Form CMS-10106 (Rev 09/17)rom 4506 Request for Copy of Tax Return
{Novmeber 2020) > Do not sign this form unless ail applicable lines have been completed. OMB No. 1545-0429
> Request may be rejected if the form is incomplete or illegible,
yf 7 4, ‘
Peleodr ot Maat > For more information about Form 4506, visit www.irs.gov/form4506.
Internal Revenue Service
Tip. You may be able to get your tax return or return information from other sources. If you had your tax return completed by a paid preparer, they
should be able to provide you a copy of the return. The IRS can provide a Tax Return Transcript for many retums free of charge. The transcript
provides most of the line entries from the original tax return and usually contains the information that a third party (such as a mortgage company)
requires. See Form 4506-T, Request for Transcript of Tax Return, or you can quickly request transcripts by using our automated self-help service
tools. Please visit us at IRS.gov and click on “Get a Tax Transcript...” or call 1-800-908-9946.
Ya Name shown on tax retum. Ifa joint return, enter the name shown first. 1b First social security number on tax return,
individual taxpayer identification number, or
Stevie Gaevle
employer identification number (see instructions)
2a If a joint return, enter spouse's name shown on tax return. 2b Second social security number or individual
taxpayer identification number if joint tax return
‘3 Current name, address (including apt., room, or suite no,), city, state, and ZIP code (see instructions)
4 Previous address shown on the last return filed if different from line 3 (see instructions)
5 If the tax return is to be mailed to a third party (such as a mortgage company), enter the third party's name, address, and telephone number.
Caution: if the tax return is being sent to the third party, ensure that lines 5 through 7 are completed before signing, (see instructions).
6 Tax return requested. Form 1040, 1120, 947, etc. and all attachments as originally submitted to the IRS, including Forme) W-2,
schedules, or amended returns. Copies of Forms 1040, 1040A, and 1040EZ are generally available for 7 years from filing before they are
destroyed by law. Other returns may be available for a longer period of time. Enter only one return number. If you need more than one
type of return, you must complete another Form 4506, >
Note: If the copies must be certified for court or administrative proceedings, checkhere. . . . ws. ee.
7 Year or period requested. Enter the ending date of the tax year or period using the mm/dd/yyyy format (see instructions).
i / / i / / / /
/ / / i i I / /
8 Fee. There is a $43 fee for each return requested. Full payment must be included with your request or it will
be rejected. Make your check or money order payable to “United States Treasury.” Enter your SSN, ITIN,
or EIN and “Form 4506 request” on your check or money order.
a Cost foreach return . a Se ate $
b Number of returns requested on line 7. eee eels
¢ Totalcost, Multiply line 8abyline8b . . 1. eee Cee $
9__ If we cannot find the tax return, we will refund the fee, If the refund should go to the third party listed on line 5, checkhere... . . LI
Caution: Do not sign this form unless all applicable lines have been completed.
Signature of taxpayer(s). | declare that | am either the taxpayer whose name is shown on line 1a or 2a, ora person authorized to obtain the lax return
requested. If the request applies to a joint retum, at least one spouse must sign. If signed by a corporate officer, 1 percent or more shareholder, partner,
managing member, guardian, tax matters partner, executor, receiver, administrator, trustee, or party other than the taxpayer, | certify that | have the authority to
execute Form 4506 on behalf of the taxpayer. Note: This form must be received by IRS within 120 days of the signature date.
CO Signatory attests that he/she has read the attestation clause and upon so reading
declares that he/she has the authority to sign the Form 4506. See instructions. Phone number of taxpayer on line
ta or2a
» Signature (see instructions) Date
Sign >
Here Print/Type name Title (ine Ta above Ts a corporation, partnership, estate, or rus)
b Spouse's signature Date
» Print/Type name
For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat, No, 41721 Form 4506 (Rev. 11-2020)Form 4506 (Rev. 11-2020)
Section references are to the Internal Revenue Code
unless otherwise noted.
Future Developments
For the latest information about Form 4506 and its
instructions, go to www.irs.gov/form4506.
General Instructions
Caution: Do not sign this form unless all applicable
lines, including lines 5 through 7, have been
completed.
Designated Recipient Notification. Internal
Revenue Code, Section 6103(¢), limits disclosure
and use of retum information received pursuant to
the taxpayer's consent and holds the recipient
subject to penalties for any unauthorized access,
other use, of redisclosure without the taxpayer's
express permission or request.
Taxpayer Notification. internal Revenue Code,
Section 6103(c), mits disclosure and use of return
information provided pursuant to your consent and
holds the recipiant subject to penalties, brought by
private right of action, for any unauthorized access,
other use, or redisclosure without your express
permission or request.
Purpose of form, Use Form 4506 to request a copy
of your tax return. You can also designate (on line 5)
a third party to receive the tax return,
How Jong will it take? It may take up to 75
calendar days for us to process your request.
Where to file. Attach payment and mail Form 4506
to the address below for the state you lived in, or the
state your business was in, when that return was
filed. There are two address charts: one for
individual returns (Form 1040 series) and one for all
other returns,
If you are requesting a return for more than one
year or period and the chart below shows two
different adcresses, send your request based on the
address of your most recent return.
(Form 1040 series)
If you filed an
individual return
and lived in:
Mail to:
Florida, Louisiana,
Mississippi, Texes, a
foreign country, American
‘Samoa, Puerto Rico,
Guam, the
Commonwealth of the
Northern Mariana Islands,
the US. Virgin Islands, or
A.P.O. or F.P.O, address
Internal Revenue Service
RAIVS Team
Stop 6716 AUSC
Austin, TX 73304
Alabama, Arkansas,
Delaware, Georgia,
ilinois, Indiana, towa,
Kentucky, Maine,
Massachusetts,
Minnesota, Missouri,
New Hampshire, New
Jersey, New York, North
Carolina, Oklahoma,
South Carolina,
Tennessee, Vermont,
Virginia, Wisconsin
Internal Revenue Service
RAIVS Team
Stop 6705 S-2
Kansas City, MO 64999
Alaska, Arizona,
California, Colorado,
Connecticut, District of
Columbia, Hawaii, Idaho,
Kansas, Maryland,
Michigan, Montana,
Nebraska, Nevada, New
Mexico, North Dakota,
Ohio, Oregon,
Pennsylvania, Rhode
Island, South Dakota,
Utah, Washington, West
Virginia, Wyoming
Internal Revenue Service
RAIVS Team
P.O. Box 9941
Mail Stop 6734
‘Ogden, UT 84409
Chart for all other returns
For returns not in
Form 1040 series,
if the address on
the return was in:
Mail to:
Conneeticut, Delaware,
District of Columbia,
Georgia, ilinois, Indiana,
Kentucky, Maine,
Maryland,
Massachusetts, internal Revenue Service
Michigan, New RAIVS Team
Hampshire, New Jersey, Stop 6705 S-2
New York, North Kansas City, MO -
Carolina, Ohio, 64999
Pennsylvania, Rhode
Island, South Carolina,
Tennessee, Vermont,
Virginia, West Virginia,
Wisconsin
Alabama, Alaska,
Arizona, Arkansas,
California, Colorado,
Florida, Hawaii, Idaho,
lowa, Kansas, Louisiana,
Minnesota, Mississippi,
Missouri, Montana,
Nebraska, Nevada, New
Mexico, North Dakota,
Oklahoma, Oregon,
South Dakota, Texas,
Utah, Washington,
Wyoming, a foreign
country, American
Samoa, Puerto Rico,
Guam, the
Commonwealth of the
Northem Mariana
Islands, the U.S. Virgin
Islands, or A.P.O. or
F.P.O. address
Internal Revenue Service
RAIVS Team
P.O. Box 9941
Mail Stop 6734
Ogden, UT 84409
Specific Instructions
Line 1b. Enter the social security number (SSN) or
individual taxpayer identification number (ITIN) for
the individual listed on line 1a, or enter the employer
identification number (EIN) for the business listed on
line ta, For example, if you are requesting Form
1040 that includes Schedule C (Form 1040), enter
your SSN,
Line 3, Enter your current address. If you use a P.O.
box, please include it on this line 3.
e 4, Enter the address shown on the last return
filed if different from the address entered on line 3.
Note. If the addresses on lines 3 and 4 are different
and you have not changed your address with the
IRS, file Form 8822, Change of Address, or Form.
8822-B,Change of Address or Responsible Party —
Business, with Form 4506,
Line 7. Enter the end date of the tax year or period
requested in mm/dd/yy format. This may be a
calendar year, fiscal year or quarter. Enter each
quarter requested for quarterly returns. Example:
Enter 12/31/2018 for a calendar year 2018 Form
1040 return, or 03/31/2017 for a first quarter Form
941 return.
Signature and date. Form 4506 must be signed and
dated by the taxpayer listed on line 1a or 2a. The
IRS must receive Form 4506 within 120 days of the
date signed by the taxpayer or it will be rejected.
Ensure that all applicable lines, including lines 5
through 7, are completed before signing.
You must check the box in the
signature area to acknowledge you
have the authority to sign and request
the information. The form will not be
processed and returned to you if the box is
unchecked.
Page 2
Individuals. Copies of jointly filed tax returns may
be furnished to either spouse. Only one signature is
required. Sign Form 4506 exactly as your name
‘appeared on the original return. if you changed your
name, also sign your current name.
Corporations. Generally, Form 4506 can be
signed by: (1) an officer having legal authority to bind
the corporation, (2) any person designated by the
board of directors or other governing body, or (3)
any officer or employee on written request by any
Principal officer and attested to by the secretary or
‘other officer. A bona fide shareholder of record
‘owning 1 percent or more of the outstanding stock
of the corporation may submit a Form 4506 but must
provide documentation to support the requester's
right to receive the information.
Partnerships. Generally, Form 4506 can be
signed by any person who was a member of the
partnership during any part of the tax period
requested on line 7.
All others. See section 6103(e) if the taxpayer has
died, is insolvent, is a dissolved corporation, or if a
trustee, guardian, executor, receiver, or
administrator is acting for the taxpayer.
Note: If you are Heir at law, Next of kin, or
Beneficiary you must be able to establish a material
interest in the estate or trust.
Documentation. For entities other than individuals,
you must attach the authorization document. For
example, this could be the letter from the principal
officer authorizing an emiployee of the corporation or
the letters testamentary authorizing an individual to
act for an estate,
Signature by a representative. A representative
‘can sign Form 4506 for a taxpayer only if this
authority has been specifically delegated to the
representative on Form 2848, line 5a. Form 2848
‘showing the delegation must be attached to Form
4508,
—_————
Privacy Act and Paperwork Reduction Act
Notice. We ask for the information on this form to
establish your right to gain access to the requested
return(s) under the Internal Revenue Code. We need
this information to properly identify the return(s) and
respond to your request. If you request a copy of a
tax return, sections 6103 and 6109 require you to
provide this information, including your SSN or EIN,
to process your request. If you do not provide this
information, we may not be able to process your
request. Providing false or fraudulent information
may subject you to penalties,
Routine uses of this information include giving it to
the Department of Justice for civil and crimina!
litigation, and cities, states, the District of Columbia,
and U.S. commonwealths and possessions for use
in administering their tax laws, We may also
Gisclose this information to other countries under a
tax treaty, to federal and state agencies to enforce
federal nontax criminal laws, or to federal law
enforcement and intelligence agencies to combat
terrorism.
‘You are not required to provide the information
requested on a form that is subject to the Paperwork.
Reduction Act unless the form displays a valid OMB
control number. Books or records relating to a form
or its instructions must be retained as long as their
contents may become material in the administration
of any Internal Revenue law. Generally, tax returns
and retum information are confidential, as required
by section 6103.
‘The time needed to complete and file Form 4508
will vary depending on individual circumstances. The
estimated average time is: Learning about the law
‘or the form, 10 min.; Preparing the form, 16 min.;
and Copying, assembling, and sending the form
to the IRS, 20 min.
Ifyou have comments concerning the accuracy of
these time estimates or suggestions for making
Form 4506 simpler, we would be happy to hear from
you. You can write to
Internal Revenue Service
Tax Forms and Publications Division
4111 Constitution Ave. NW, 17-6526
Washington, DC 20224,
Do not send the form to this address. Instead, see
Where to file on this page.
Preview
Filing # 124034035 E-Filed 03/30/2021 03:40:26 PM IN THE CIRCUIT COURT OF THE 17™ JUDICIAL CIRCUIT IN AND FOR BROWARD COUNTY, FLORIDA Case No. CACE-21-003836 Div. 09 STEVIE BAZILE, individually, and WILSON JEAN LOUIS, her husband, v. Plaintiffs, COMPLETE HIGHWAY IMPROVEMENT, INC., A Florida Corporation, CITY OF NORTH LAUDERDALE, And WESNER ABRAHAM, individually, Defendants. / DEFENDANT, CITY OF NORTH LAUDERDALE’S FIRST REQUEST FOR PRODUCTION TO PLAINTIFF Defendant, CITY OF NORTH LAUDERDALE (‘‘City”), by and through its undersigned attorneys and pursuant to Rule 1,350 of Florida Rules of Civil Procedure, requests Plaintiff, STEVIE BAZILE (“Plaintiff”), produce within thirty (30) days of the date of this Request at the office of the undersigned, the following: 1, Individual and/or joint income tax returns corporate returns and any other supporting documentation, including W-2 forms, for the five (5) years preceding the alleged accident/incident to date or any other evidence of income for each of said years. If there are returns requested which you do not have in your immediate possession or custody, please fill out and sign the enclosed release and return it in response to this request. All documentation which would reflect Plaintiffs earnings for the present year to date (this would include payroll stubs, canceled checks, computer printouts of earnings to date, etc.). Any and all medical, doctor, hospital, drug, nursing and ambulance medical records, reports, bills, and invoices (including any members of the healing arts and related fields: i.e. drugs, prosthetics, supports, etc.) pertaining to the Plaintiff, to the extent they pertain to any and all injuries or damages you alleged were caused by the incident giving rise to this lawsuit pertaining to any treatment described in your answers to interrogatories. This request also seeks documentation for any expenses that you claim you have incurred as a result of this accident/incident, which includes but is not limited to bills and invoices for household assistance and out-of-pocket expenses, etc. If there are medical records and *** FILED: BROWARD COUNTY, FL BRENDA D. FORMAN, CLERK 03/30/2021 03:40:25 PM.****16. documents requested which you do not have in your possession or custody, please fill out and execute the attached medical records release and return it in response to this request. All x-rays, cat scans, MRIs, EKGs, EEGs and/or other scans of the Plaintiff, to the extent they pertain to any and all injuries or damages you allege were caused by the incident giving rise to this lawsuit or pertaining to any treatment described in your answers to interrogatories. If there are x-rays or scans requested which you do not have in your immediate possession or custody, please fill out and sign the enclosed medical records release and return it in response to this request. All medical bills and/or statements, correspondence (including but not limited to letters of protection), and related documents for services rendered to the Plaintiff, paid or unpaid, as an alleged result of the incident giving rise to this suit, including any bills for drugs or other related expenses. All bills, statements, or receipts relating to an expense claimed as damages in this lawsuit which have not been produced in response to any of the preceding paragraphs. All reports and related documents related to any issue in this lawsuit which have been prepared by experts that you intend to call as witnesses in this cause. All statements taken from any agents or employees of Defendant regarding the incident sued upon. All photographs, diagrams, sketches, or other documents depicting the scene of the alleged incident. . All photographs, diagrams, sketches, or other documents depicting your injuries or damages. . All statements taken from any witnesses having knowledge regarding the facts and circumstances surrounding the happening of the incident complained of herein. . All documents pertaining to the sued-upon incident or your physical condition or damages. . All releases, "Mary Carter Agreements," and any other type of settlement documents between the Plaintiff and any other party which may have been responsible for the alleged damages claimed by the Plaintiff. - All photographs, recordings, charts, graphs, sketches and any other documents or tangible items which you intend to use during the trial of this cause and which have not been produced in response to any of the preceding paragraphs. . All documents which you identify in response to Interrogatories served this date. All documents which you contend support your compliance with all conditions precedent to bringing this action.20. 21. 22. 23. 24, 25. 26. 27. 28. 29. . Your Medicare card. . Your Medicaid card. . Your Social Security Disability card. Your Supplemental Security Income card. Your applications for Medicare or Medicaid benefits during the past 10 years. Your applications for Social Security benefits including but not limited to Social Security Disability and/or Supplemental Security Income benefits during the past 10 years. All Social Security award letters you have received during the past 10 years. All documents regarding any and all Medicare benefits identified in your Answer to the Medicare Interrogatories served on this date. All documents regarding any and all Medicaid benefits identified in your Answer to Medicare Interrogatories served on this date. All documents regarding your current Medicare, Medicaid, Social Security Disability and/or Supplemental Security Income recipient status as identified in your Answers to the Interrogatories served on this date. All documents and communications regarding any and all requests for hearing for Social Security Disability and/or Supplemental Security Income benefits identified in Answer the Interrogatories served on this date. So that both parties can be in full compliance with all Medicare reporting and reimbursement requirements, a complete and executed two forms: CMS (A-1) and Authorization Form (marked as A-2), attached. As to each type of insurance in force of favor of the Plaintiff, including, but not limited to, medical insurance, hospitalization insurance, Medicare, Medicaid, disability insurance, medical payments insurance, personal injury protection, health insurance and accident insurance: Copies of each such contract or policy; The Identification Card of each such contract policy; The Declaration Sheet of each such contract or policy: Each and every application for benefits made by the Plaintiff under any of the policies, whether pertaining to the accident which is the subject of this litigation or not; e. All records or payments, checks, check stubs, memos and correspondence relating to payments made under any of the policies referred to above; and BeoPpf. All documents reflecting billing codes including but not limited to ICD9 codes relating to Medicare coverage, treatment, and payments. 30. Any and all photographs intended to be used at trial depicting any all parties and/or witnesses, the injury and the damages sustained by the person(s) involved in the accident/incident herein, the scene and/or site of the accident/incident as described in your Complaint. 31. All reports, evaluations, recommendations and/or analysis submitted by any expert which relate to or cover the accident/incident which is the subject matter of this lawsuit and/or any injuries, damages or losses allegedly caused by the accident/incident. 32. Copies of any and all medical reports and/or records from doctors, physicians (including chiropractors), hospitals, or anyone else of the healing arts who has rendered treatment to you or examined you subsequent to the accident/incident herein which is the subject matter of this lawsuit. (This would include both treating physicians as well as independent medical exams). 33. Copies of any and all writings, recordings, memorandums, notes, depositions, and all other materials reflecting statements made by the Defendant. 34. Legible copies of all applications filled out by you for Personal Injury Protection Benefits (No fault Insurance Benefits) by the accident/incident which is the subject matter of this lawsuit. 35. Legible copies of all applications filled out by you for any type of insurance coverage for which you are submitting an application to obtain benefits for any of your damages and/or wages of the accident/incident as alleged in your Complaint. 36. Legible copies of each and every document, chart, paper, graph, employment record, payroll record, time sheets and/or other writings of any type evidencing each and every day or partial day, you claim to have missed from work as a result of the accident/incident which is the subject matter of this lawsuit. 37. Legible copies of any and all checks, PIP payout sheets and/or writings that indicate the amount of money, if any, that you have received as reimbursement for lost wages, medical bills (or other bills) from your Personal Injury Protection Policy or any other collateral sources. 38. Legible copies of any and all letters of subrogation rights or liens being asserted by any third party/entity as a result of any damages you have sustained as a result of the accident/incident as described in the Complaint. 39. Legible copies of any and all reports, charts, graphs, or other writings from any vocational specialist, rehabilitative consultants and/or other experts that have assisted you or evaluated you with regard to damages claimed in this lawsuit.40. Legible copies of any and all diagnostic test results, including but not limited to x-rays, CT scans, MRI films, EMG, NCS, and other electrical studies that were performed on the claimant(s) as a result of the accident which is the subject matter of this lawsuit. . Production of all diagnostic test results of any and all x-rays, CAT scans, CT scans, MRI scans, ultrasounds, thermograms, EMG and NCS studies that were performed on you during the five-year period prior to the accident/incident as described in your Complaint. tS 42. Legible copies of the front and back of any and all insurance indemnification card and union employment identification cards which would depict the name, address, policy number, claim number and/or identification number of any insurance company and/or employers which will provide you with any benefits to compensate you for any of the damages that you are alleging as a result of the accident/incident which is the subject matter of this lawsuit. 43. Any and all statements, documents, correspondence, chart, or other writing of any type taken from Plaintiffs employers and/or their agents pertaining to employment, wage loss, loss of future earning capacity or the loss of the ability to earn money in the future which would support your allegations in the Complaint. 44, Please provide legible copies of any and all accident reports, incident reports or other reports that were generated as a result of the accident/incident that is the subject matter of your Complaint. 45. Incident reports and/or traffic accident reports for any and all accidents that you have been involved in within the ten (10) year period before the accident giving rise to this case, and for any and all accidents that you have been involved in since the occurrence of the accident which is the subject matter of this lawsuit. 46. Please provide legible copies of any Notice of Injury forms that you have filled out for any workman's compensation claim, or workman's compensation notice, that you are required to fill out as a result of any type of on-the-job injury or incident for the past five (5) years to date. 47. Copies of any and all life, health, or disability insurance policies covering the claimant in this lawsuit that were in full force and effect on the date of the accident which is the subject matter of this lawsuit. 48. Copies of any and all statements taken of any witnesses (written or recorded) as a result of the accident/incident which is the subject matter of this lawsuit. 49. Copies of the front and back of all driver's licenses in your possession. 50. Copies of any Florida identification cards, front and back. 51. A complete copy of your passport.52 53. 54. 55. 56. 57. Copies of any Releases you may have executed to any party, person, entity for personal injuries that you may have sustained or property damage you suffered in the past twenty (20) years. Please provide legible copies of all medical reports and records that were made by and physicians or chiropractor regarding any examination that was conducted upon you at the request of any insurance company or insurance adjusting company (otherwise known as IME's, independent evaluations, medical evaluations, or physical examinations) which occurred as a consequence of the accident/incident as described in your Complaint. Please provide legible copies of all medical reports and records that were made by and physician or chiropractor regarding any examination that was conducted upon you at the request of any insurance company or insurance adjusting company (otherwise known as IME's, independent evaluations, medical evaluations, or physical examinations) for the five (5) years prior to the incident. Copies of any calendars, diaries, notes, or other documentation made by you which memorializes any appointments, your condition, thoughts, damages, or any other item of damages you intend to present to the jury at the trial of this case. Please execute and return the attached authorization for the release of insurance, hospital records, medical records, and medical billing information pertaining to the Plaintiff for all the medical providers for whom the Plaintiff has received medical treatment for any reason prior to the incident described in the Complaint and for any time after the incident described in the Complaint. Please execute and return the attached authorization for the release of tax returns and records. (PLEASE NOTE: The original authorization must be mailed back to undersigned counsel. A photocopy is not acceptable).CERTIFICATE OF SERVICE I HEREBY CERTIFY that a copy hereof has been served and filed through the Florida Court E-Filing Portal thisdD Tsay of March, 2021 to: Brett R. Bloch, Esq., Shendell & Pollock, P.L., 2700 North Military Trail, Suite 150, Boca Raton, FL, 33431, brett @shendellpollock.com, lisak@shendellpollock.com, Stephanie@shendellpollock.com, grs@shendellpollock.com, Ian D. Pinkert, Esq., Jay Halpern & Associates, PA, 150 Alhambra Circle, Suite 100, Coral Gables, Florida, 33134, ian@hsptrial.com. MELISSA L. JOHNSG FLA. BAR NO. 275. Attorney for City of North Lauderdale JOHNSON, ANSELMO, MURDOCH, BURKE, PIPER & HOCHMAN, P.A. 2455 E. Sunrise Blvd., Suite 1000 Fort Lauderdale, FL 3330 Tel: 954-463-0100/Fax: 954-463-2444- mljohnson@jambg.com berens@jambg.com finley@jambg.comAUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION AND RECORDS (HIPAA COMPLIANT TO: STEVIE BAZILE DOB: SOC SEC.: YOU ARE HEREBY INSTRUCTED AND REQUESTED to release to Melissa L. Johnson, Esq., Johnson, Anselmo, Murdoch, Burke, Piper & Hochman, P.A., 2455 E. Sunrise Blvd., Suite 1000, Fort Lauderdale, FL 33304; (954) 463-0100., the following: YOUR ENTIRE FILE INCLUDING BUT NOT LIMITED TO ANY AND ALL medical, insurance, hospital, psychiatric, or other mental health treatment records, reports, admission and discharge summaries, consultations, nurses’ notes, diagnostic tests. reports of x-rays, CT Scans, MRI notes; documents; reports; test results; diagnostic studies; results of examinations conducted; correspondence; any and all X-rays, CT scans, MRI films, and all other radiographic studies and associated reports, results, interpretations; all pathology slides, tissue blocks, specimens, etc., all other pathologic studies and associated reports, results, interpretations; consultation reports, inpatient, emergency or out-patient records, photographs, any and all bills for services rendered, HIV testing records/results; psychological/psychiatric records, including, but not limited to, substance abuse counseling records and HIV counseling records; and copies of all other materials ete., bills, correspondence or other documentary or tangible items regarding my mental or physical condition while under your observation or treatment, and to permit the examination of, and the copying of records pertaining thereto. This facility is released and discharged of any liability and the undersigned will hold the facility harmless for complying with this "Authorization for Release of Medical Information." This Authorization is valid through the completion of litigation styled STEVIE BAZILE, individually, and WILSON JEAN LOUIS, her husband, Case No.: CACE-21- 003836 Div. 09. A PHOTOSTATIC COPY OF THIS AUTHORIZATION SHOULD LIKEWISE BE HONORED, (THIS SECTION HAS BEEN INTENTIONALLY LEFT BLANK) (Page | of 2)AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION AND RECORDS (HIPAA COMPLIANT. STEVIE BAZILE STATE OF FLORIDA ) )ss COUNTY OF ) Sworn to (or affirmed) and subscribed before me by means of physical presence or online notarization, who after being first duly sworn, deposes and states that he/she answered the Interrogatories, and the facts contained therein are true and correct to the best of his/her knowledge and belief. SWORN TO AND SUBSCRIBED before me this day of : 2021, by 7 . who is personally known to me, or who has produced _ as identification. Notary Public, State of Florida at Large Printed Name:_ (NOTARY SEAL) My commission expires: (Page 2 of 2)CATS, AL Medicare Beneficiary Services: 1-800-MEDICARE (1-800-633-4227) (CENTERS for MEDICARE & MEDICAID SERVICES. TTY/1DD:1-877-486-2048 This form is used to advise Medicare of the person or persons you have chosen to have access to your personal health information. Where to Return Your Completed Authorization Forms: After you complete and sign the authorization form, return it to the address below: Medicare BCC, Written Authorization Dept. PO Box 1270 Lawrence, KS 66044 For New York Medicare Beneficiaries ONLY The New York State Public Health Law protects information that reasonably could identify someone as having HIV symptoms or infection, and information regarding a person's contacts. Because of New York's laws protecting the privacy of information related to alcohol and drug abuse, mental health treatment, and HIV, there are special instructions for how you, as a New York resident, should complete this form. * For question 2A, check the box for Limited Information, even if you want to authorize Medicare to release any and all of your personal health information. ¢ Then proceed to question 2B, Medicare BCC. Written Authorization Dept. PO Box 1270 Lawrence, KS 66044FORM A-2 Authorization to Release Information nawe: STevie Caria (if applicable, exactly as shown on your Medicare card) SOCIAL SECURITY NUMBER: MEDICARE NUMBER (HICN): (if applicable, the number on your Medicare card) DATE OF BIRTH: DATE OF INJURY/ILLNESS: In compliance with the Federal Privacy Act of 1974 and the HIPAA Privacy Rule, the undersigned authorizes the Centers for Medicare &Medicaid Services (CMS), and their contractors, to release to or its/their designee(s), agent(s) and representative(s) (collectively "the Company") any and all information concerning conditional payments made by Medicare resulting from the personal injury/illness, which occurred/was diagnosed on or about the date listed above. The undersigned also hereby authorizes the Company to disclose my personal-information (including but not limited to my Social Security number) and information related to my injury/illness and any settlement for the specified injury/illness to CMS and its contractors. The undersigned also hereby authorizes the Company to disclose my Social Security number to the Social Security Administration to determine social security benefits (for the purposes of determining Medicare eligibility). This form expires in three years from the date of execution; however, | understand that | may revoke this "Authorization to Release Information" at any time. SIGNED: DATE:Instructions for Completing Section 2B of the Authorization Form: Please select one of the following options. * Option 1 To include all information, in the space provided, write: "all information, including information about alcoho! and drug abuse, mental health treatment, and HIV". Proceed with the rest of the form. * Option 2 To exclude the information listed above, write "Exclude information about alcohol and drug abuse, mental health treatment and HIV" in the space provided. You may also check any of the remaining boxes and include any additional limitations in the Space provided. For example, you could write "payment information". Then proceed with the rest of the form. . If you have any questions or need additional assistance, please feel free to call us at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, Sincerely, 1-800-MEDICARE Customer Service Representative Encl.Information to Help You Fill Out the “1-800-MEDICARE Authorization to Disclose Personal Health Information” Form By law, Medicare must have your written permission (an “authorization”) to use or give out your personal medical information for any purpose that isn't set out in the privacy notice contained in the Medicare & You handbook. You may take back (revoke”) your written permission at any time, except if Medicare has already acted based on your permission. If you want 1-800-MEDICARE to give your personal health information to someone other than you, you need to let Medicare know in writing. If you are requesting personal health information for a deceased beneficiary, please include a copy of the legal documentation which indicates your authority to make a request for information. (For example: Executor/Executrix papers, next of kin attested by court documents with a court stamp and a judge's signature, a Letter of Testamentary or Administration with a court stamp and judge's signature, or personal representative papers with a court stamp and Judge's signature.) Also, please explain your relationship to the beneficiary. Please use this step by step instruction sheet when completing your “1-800- MEDICARE Authorization to Disclose Personal Health Information” Form. Be sure to complete all sections of the form to ensure timely processing. 1. Print the name of the person with Medicare. Print the Medicare number exactly as it is shown on the red, white, and blue Medicare card, including any letters (for example, 1234567894). Print the birthday in month, day, and year (mm/dd/yyyy) of the person with Medicare, 2, This section tells Medicare what personal health information to give out. Please check a box in 2a to indicate how much information Medicare can disclose, If you only want Medicare to give out limited information (for example, Medicare eligibility), also check the box(es) in 2b that apply to the type of information you want Medicare to give out. 3. This section tells Medicare when to start and/or when to stop giving out your personal health information. Check the box that applies and fill in dates, if necessary, 4, Medicare will give your personal health information to the person(s) or organization(s) you fill in here. You may fill in more than one person or organization. If you designate an organization, you must also identify one or more individuals in that organization to whom Medicare may disclose your personal health information,x . The person with Medicare or personal representative must sign their name, fill in the date, and provide the phone number and address of the person with Medicare. If you are a personal representative of the person with Medicare, check the box, provide your address and phone number, and attach a copy of the paperwork that shows you can act for that person (for example, Power of Attomey). Send your completed, signed authorization to Medicare at the address shown here on your authorization form. If you change your mind and don't want Medicare to give out your personal health information, write to the address shown under number six on the authorization form and tell Medicare. Your letter will revoke your authorization and Medicare will no longer give out your personal health information (except for the personal health information Medicare has already given out based on your permission). You should make a copy of your signed authorization for your records before mailing it to Medicare.Department of Health and Human Services Form Approved OMB No. 0938-0930 Centers for Medicare & Medicaid Services. 1-800-MEDICARE Authorization to Disclose Personal Health Information Use this form if you want 1-800-MEDICARE to give your personal health information to someone other than you. STé vie. Eazile 1. Print Name Medicare Number Date of Birth (First and last name of the person with Medicare) (Exactly as shown on the Medicare Card) (mm/dd/yyyy) 2, Medicare will only disclose the personal health information you want disclosed. 2A: Check only one box below to tell Medicare the specific personal health information you want disclosed: C] Limited Information (go to question 2b) LF Any Information (go to question 3) 2B: Complete only if you selected “limited information”. Check all that apply: [J Information about your Medicare eligibility | Information about your Medicare claims [] Information about plan enrollment (e.g. drug or MA Plan) LC] Information about premium payments CE Other Specific Information (please write below; for example, payment information) 2C: NY Residents Only, this section must be completed. Please select one of the following options: (Please check only one box.) | Include all information. This includes information about alcohol and drug abuse, mental health treatment, and HIV. OR C] Exclude information about alcohol and drug abuse, mental health treatment, and HIV. Form CMS-10106 (Rev 09/17)Department of Health and Human Services Form Approved Centers for Medicare & Medicaid Services OMB No. 0938-0930 3. Check only one box below indicating how long Medicare can use this authorization to disclose your personal health information (subject to applicable law—for example, your State may limit how long Medicare may give out your personal health information): LI Disclose my personal health information indefinitely EC] Disclose my personal health information for a specified period only beginning: (mm/dd/yyyy) and ending: (mm/dd/yyyy) 4. Fill in the reason for the disclosure (you may write "at my request"): 5. Fill in the name and address of the person or organization to whom you want Medicare to disclose your personal health information. Please provide the specific name of the person for any organization you list below. If you would like to authorize any additional individuals or organizations, please add those to the back of this form. Name Address Name Address Form CMS-10106 (Rev 09/17)Department of Health and Human Services Form Approved Centers for Medicare & Medicaid Services OMB No. 0938-0930 Note: You have the right to take back (“revoke”) your authorization at any time, in writing, except to the extent that Medicare has already acted based on your permission. To revoke authorization, send a written request to the address noted below. Y our authorization or refusal to authorize disclosure of your personal health information will have no effect on your enrollment, eligibility for benefits, or the amount Medicare pays for the health services you receive. 6. I authorize 1-800-MEDICARE to disclose my personal health information listed above to the person(s) or organization(s) I have named on this form. I understand that my personal health information may be re-disclosed by the person(s) or organization(s) and may no longer be protected by law. Signature Telephone Number Date (mm/dd/yyyy) Print the address of the person with Medicare (Street Address, City, State, and ZIP) C] Check here if you are signing as a personal representative and complete below. Please attach the appropriate documentation (for example, Power of Attorney). This only applies if someone other than the person with Medicare signed above. Print the Personal Representative's Address (Street Address, City, State, and ZIP) Telephone Number of Personal Representative: Personal Representative's Relationship to the Beneficiary: Form CMS-10106 (Rev 09/17)rom 4506 Request for Copy of Tax Return {Novmeber 2020) > Do not sign this form unless ail applicable lines have been completed. OMB No. 1545-0429 > Request may be rejected if the form is incomplete or illegible, yf 7 4, ‘ Peleodr ot Maat > For more information about Form 4506, visit www.irs.gov/form4506. Internal Revenue Service Tip. You may be able to get your tax return or return information from other sources. If you had your tax return completed by a paid preparer, they should be able to provide you a copy of the return. The IRS can provide a Tax Return Transcript for many retums free of charge. The transcript provides most of the line entries from the original tax return and usually contains the information that a third party (such as a mortgage company) requires. See Form 4506-T, Request for Transcript of Tax Return, or you can quickly request transcripts by using our automated self-help service tools. Please visit us at IRS.gov and click on “Get a Tax Transcript...” or call 1-800-908-9946. Ya Name shown on tax retum. Ifa joint return, enter the name shown first. 1b First social security number on tax return, individual taxpayer identification number, or Stevie Gaevle employer identification number (see instructions) 2a If a joint return, enter spouse's name shown on tax return. 2b Second social security number or individual taxpayer identification number if joint tax return ‘3 Current name, address (including apt., room, or suite no,), city, state, and ZIP code (see instructions) 4 Previous address shown on the last return filed if different from line 3 (see instructions) 5 If the tax return is to be mailed to a third party (such as a mortgage company), enter the third party's name, address, and telephone number. Caution: if the tax return is being sent to the third party, ensure that lines 5 through 7 are completed before signing, (see instructions). 6 Tax return requested. Form 1040, 1120, 947, etc. and all attachments as originally submitted to the IRS, including Forme) W-2, schedules, or amended returns. Copies of Forms 1040, 1040A, and 1040EZ are generally available for 7 years from filing before they are destroyed by law. Other returns may be available for a longer period of time. Enter only one return number. If you need more than one type of return, you must complete another Form 4506, > Note: If the copies must be certified for court or administrative proceedings, checkhere. . . . ws. ee. 7 Year or period requested. Enter the ending date of the tax year or period using the mm/dd/yyyy format (see instructions). i / / i / / / / / / / i i I / / 8 Fee. There is a $43 fee for each return requested. Full payment must be included with your request or it will be rejected. Make your check or money order payable to “United States Treasury.” Enter your SSN, ITIN, or EIN and “Form 4506 request” on your check or money order. a Cost foreach return . a Se ate $ b Number of returns requested on line 7. eee eels ¢ Totalcost, Multiply line 8abyline8b . . 1. eee Cee $ 9__ If we cannot find the tax return, we will refund the fee, If the refund should go to the third party listed on line 5, checkhere... . . LI Caution: Do not sign this form unless all applicable lines have been completed. Signature of taxpayer(s). | declare that | am either the taxpayer whose name is shown on line 1a or 2a, ora person authorized to obtain the lax return requested. If the request applies to a joint retum, at least one spouse must sign. If signed by a corporate officer, 1 percent or more shareholder, partner, managing member, guardian, tax matters partner, executor, receiver, administrator, trustee, or party other than the taxpayer, | certify that | have the authority to execute Form 4506 on behalf of the taxpayer. Note: This form must be received by IRS within 120 days of the signature date. CO Signatory attests that he/she has read the attestation clause and upon so reading declares that he/she has the authority to sign the Form 4506. See instructions. Phone number of taxpayer on line ta or2a » Signature (see instructions) Date Sign > Here Print/Type name Title (ine Ta above Ts a corporation, partnership, estate, or rus) b Spouse's signature Date » Print/Type name For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat, No, 41721 Form 4506 (Rev. 11-2020)Form 4506 (Rev. 11-2020) Section references are to the Internal Revenue Code unless otherwise noted. Future Developments For the latest information about Form 4506 and its instructions, go to www.irs.gov/form4506. General Instructions Caution: Do not sign this form unless all applicable lines, including lines 5 through 7, have been completed. Designated Recipient Notification. Internal Revenue Code, Section 6103(¢), limits disclosure and use of retum information received pursuant to the taxpayer's consent and holds the recipient subject to penalties for any unauthorized access, other use, of redisclosure without the taxpayer's express permission or request. Taxpayer Notification. internal Revenue Code, Section 6103(c), mits disclosure and use of return information provided pursuant to your consent and holds the recipiant subject to penalties, brought by private right of action, for any unauthorized access, other use, or redisclosure without your express permission or request. Purpose of form, Use Form 4506 to request a copy of your tax return. You can also designate (on line 5) a third party to receive the tax return, How Jong will it take? It may take up to 75 calendar days for us to process your request. Where to file. Attach payment and mail Form 4506 to the address below for the state you lived in, or the state your business was in, when that return was filed. There are two address charts: one for individual returns (Form 1040 series) and one for all other returns, If you are requesting a return for more than one year or period and the chart below shows two different adcresses, send your request based on the address of your most recent return. (Form 1040 series) If you filed an individual return and lived in: Mail to: Florida, Louisiana, Mississippi, Texes, a foreign country, American ‘Samoa, Puerto Rico, Guam, the Commonwealth of the Northern Mariana Islands, the US. Virgin Islands, or A.P.O. or F.P.O, address Internal Revenue Service RAIVS Team Stop 6716 AUSC Austin, TX 73304 Alabama, Arkansas, Delaware, Georgia, ilinois, Indiana, towa, Kentucky, Maine, Massachusetts, Minnesota, Missouri, New Hampshire, New Jersey, New York, North Carolina, Oklahoma, South Carolina, Tennessee, Vermont, Virginia, Wisconsin Internal Revenue Service RAIVS Team Stop 6705 S-2 Kansas City, MO 64999 Alaska, Arizona, California, Colorado, Connecticut, District of Columbia, Hawaii, Idaho, Kansas, Maryland, Michigan, Montana, Nebraska, Nevada, New Mexico, North Dakota, Ohio, Oregon, Pennsylvania, Rhode Island, South Dakota, Utah, Washington, West Virginia, Wyoming Internal Revenue Service RAIVS Team P.O. Box 9941 Mail Stop 6734 ‘Ogden, UT 84409 Chart for all other returns For returns not in Form 1040 series, if the address on the return was in: Mail to: Conneeticut, Delaware, District of Columbia, Georgia, ilinois, Indiana, Kentucky, Maine, Maryland, Massachusetts, internal Revenue Service Michigan, New RAIVS Team Hampshire, New Jersey, Stop 6705 S-2 New York, North Kansas City, MO - Carolina, Ohio, 64999 Pennsylvania, Rhode Island, South Carolina, Tennessee, Vermont, Virginia, West Virginia, Wisconsin Alabama, Alaska, Arizona, Arkansas, California, Colorado, Florida, Hawaii, Idaho, lowa, Kansas, Louisiana, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Mexico, North Dakota, Oklahoma, Oregon, South Dakota, Texas, Utah, Washington, Wyoming, a foreign country, American Samoa, Puerto Rico, Guam, the Commonwealth of the Northem Mariana Islands, the U.S. Virgin Islands, or A.P.O. or F.P.O. address Internal Revenue Service RAIVS Team P.O. Box 9941 Mail Stop 6734 Ogden, UT 84409 Specific Instructions Line 1b. Enter the social security number (SSN) or individual taxpayer identification number (ITIN) for the individual listed on line 1a, or enter the employer identification number (EIN) for the business listed on line ta, For example, if you are requesting Form 1040 that includes Schedule C (Form 1040), enter your SSN, Line 3, Enter your current address. If you use a P.O. box, please include it on this line 3. e 4, Enter the address shown on the last return filed if different from the address entered on line 3. Note. If the addresses on lines 3 and 4 are different and you have not changed your address with the IRS, file Form 8822, Change of Address, or Form. 8822-B,Change of Address or Responsible Party — Business, with Form 4506, Line 7. Enter the end date of the tax year or period requested in mm/dd/yy format. This may be a calendar year, fiscal year or quarter. Enter each quarter requested for quarterly returns. Example: Enter 12/31/2018 for a calendar year 2018 Form 1040 return, or 03/31/2017 for a first quarter Form 941 return. Signature and date. Form 4506 must be signed and dated by the taxpayer listed on line 1a or 2a. The IRS must receive Form 4506 within 120 days of the date signed by the taxpayer or it will be rejected. Ensure that all applicable lines, including lines 5 through 7, are completed before signing. You must check the box in the signature area to acknowledge you have the authority to sign and request the information. The form will not be processed and returned to you if the box is unchecked. Page 2 Individuals. Copies of jointly filed tax returns may be furnished to either spouse. Only one signature is required. Sign Form 4506 exactly as your name ‘appeared on the original return. if you changed your name, also sign your current name. Corporations. Generally, Form 4506 can be signed by: (1) an officer having legal authority to bind the corporation, (2) any person designated by the board of directors or other governing body, or (3) any officer or employee on written request by any Principal officer and attested to by the secretary or ‘other officer. A bona fide shareholder of record ‘owning 1 percent or more of the outstanding stock of the corporation may submit a Form 4506 but must provide documentation to support the requester's right to receive the information. Partnerships. Generally, Form 4506 can be signed by any person who was a member of the partnership during any part of the tax period requested on line 7. All others. See section 6103(e) if the taxpayer has died, is insolvent, is a dissolved corporation, or if a trustee, guardian, executor, receiver, or administrator is acting for the taxpayer. Note: If you are Heir at law, Next of kin, or Beneficiary you must be able to establish a material interest in the estate or trust. Documentation. For entities other than individuals, you must attach the authorization document. For example, this could be the letter from the principal officer authorizing an emiployee of the corporation or the letters testamentary authorizing an individual to act for an estate, Signature by a representative. A representative ‘can sign Form 4506 for a taxpayer only if this authority has been specifically delegated to the representative on Form 2848, line 5a. Form 2848 ‘showing the delegation must be attached to Form 4508, —_———— Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to establish your right to gain access to the requested return(s) under the Internal Revenue Code. We need this information to properly identify the return(s) and respond to your request. If you request a copy of a tax return, sections 6103 and 6109 require you to provide this information, including your SSN or EIN, to process your request. If you do not provide this information, we may not be able to process your request. Providing false or fraudulent information may subject you to penalties, Routine uses of this information include giving it to the Department of Justice for civil and crimina! litigation, and cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws, We may also Gisclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. ‘You are not required to provide the information requested on a form that is subject to the Paperwork. Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and retum information are confidential, as required by section 6103. ‘The time needed to complete and file Form 4508 will vary depending on individual circumstances. The estimated average time is: Learning about the law ‘or the form, 10 min.; Preparing the form, 16 min.; and Copying, assembling, and sending the form to the IRS, 20 min. Ifyou have comments concerning the accuracy of these time estimates or suggestions for making Form 4506 simpler, we would be happy to hear from you. You can write to Internal Revenue Service Tax Forms and Publications Division 4111 Constitution Ave. NW, 17-6526 Washington, DC 20224, Do not send the form to this address. Instead, see Where to file on this page.